Pentoxifylline and tocopherol for the treatment of osteoradionecrosis of the jaws. A systematic review

Background: Osteoradionecrosis of the jaws (ORNJ) is a severe and challenging complication of head and neck radiation therapy. Despite its aggressiveness and controversy respect to its efficacy, surgical intervention remains the main treatment modality. Nevertheless, due to advances in the understanding of ORNJ physiopathology, new treatment alternatives such as the combination of pentoxifylline with tocopherol (PENTO) have emerged. The aim of this systematic review was to assess the reported efficacy of PENTO for the treatment of ORNJ. Material and Methods: Studies were search using Pubmed, The Cochrane Library, Scopus, and Web of Science data bases following the PRISMA guidelines. Inclusion criteria were cohort, case series, randomized or non-randomized clinical studies published in English including human subjects who received PENTO as treatment for ORN of the jaws. Results: Eleven articles met the inclusion criteria and were included for data analysis. All studies reported patients with complete mucosal coverage with no exposed bone (considered healthy) after PENTO treatment, ranging from 16.6% to 100% of the patients, depending on the study. Clinical improvement or disease stabilization was reported between 7.6% and 66.6% of studied individuals, while disease progression was seen in only 5 studies involving 7.6 - 32% of patients. Conclusions: PENTO treatment achieved a complete disease control in a significant number of patients in all studies. However, there is no standardized protocol for administering the therapy. It is necessary to determine the pharmacological doses and to evaluate the benefits of adding antibiotics and clodronate. Good quality clinical trials are needed to develop a successful algorithm for the management of ORN of the jaws. (AU)

Incidence of mandibular osteoradionecrosis (MORN) after intensity modulated radiotherapy (IMRT) versus 3D conformal radiotherapy (3D-CRT): A systematic review

Background: Analyze the incidence of MORN after head and neck radiotherapy by two novel irradiation techniques, 3DCRT and IMRT and compare the success rates of distinct authors.Material and methods: An electronic search in Pubmed (MEDLINE), Ovid, Google Scholar and Cochrane Library (Wiley), databases was conducted with the key words "Radiotherapy, Conformal"[Mesh] OR "Radiotherapy, Intensity-Modulated"[Mesh]) AND "Osteoradionecrosis"[Mesh] for all databases. The inclusion criteria randomized controlled trials (RCT), as well as prospective and retrospective cohort studies published in English; MORN patients treated with 3D-CRT y IMRT. Results: 27 articles were selected from 194 initially found. 14 articles out of 27 were excluded and finally included 8 publications were included in the systematic review that were ranked according to their level of scientific evidence using the SORT criteria. Conclusions: When both RT techniques were compared; IMRT revealed a lower risk incidence of MORN development and enhanced dose constraint than 3D-CRT (less than 10%), this improvement could translate into less complications post RT treatment. (AU)

Therapeutic alternatives in the management of osteoradionecrosis of the jaws. Systematic review / Alternativas terapéuticas en el manejo de osteorradionecrosis de los maxilares. Revisión sistemática

Background: to systematically review the literature, comparing the healing of osteoradionecrosis (ORN) amongthe therapeutic alternatives: surgical, pharmacological and combined.Material and Methods: The review was organized according to the PRISMA protocol with regards to the fol-lowing PICO question: patients with ORN of the jaws (P=Patient); all interventions reported (I = intervention);between all therapies (C=Comparison); healing of lesions (O=outcome).Results: Surgical treatment was the most common choice (46.3%) followed by pharmacological treatment, exclu-sively (25.9%) or combined (26.9%). Treatment exclusively by surgical intervention seems to be most effectiveoption, with 51.2% of the lesions healed, OR for healing of 5.7 (CI95% 1.9-16.9, p=0.002). Only 1 case (0.9%) cor-responded to low level laser therapy.Conclusions: It seems clear that early intervention with conservative surgical combined with pharmacologicalmethods improves the prognosis of ORN.(AU)

Leukocyte- and platelet-rich fibrin does not provide any additional benefit for tooth extraction in head and neck cancer patients post-radiotherapy: a randomized clinical trial

BACKGROUND: One of the most important complications of radiotherapy (RT) for head and neck cancer (HNC) is osteoradionecrosis (ORN) of the jaws, arising mainly from tooth extractions. Thus, the present study aimed to evaluate the efficacy of leukocyte- and platelet-rich fibrin (L-PRF) in preventing ORN following tooth extraction in post-irradiated HNC patients, as well as other postoperative complications. MATERIAL AND METHODS: 23 patients previously submitted to conventionally fractionated 3D-conformational RT for HNC underwent atraumatic tooth extractions with perioperative antibiotic therapy. Besides, they were randomly as-signed to receive L-PRF clots to fill and cover the extraction sockets (n = 11, Test Group) or not (n = 12, Control Group). A visual analog scale was used to quantify postoperative pain on the 3rd and 7th days. For ORN diagnosis, patients were clinically assessed for up to 180 days. Other postoperative complications (edema, alveolitis, suture dehiscence, continuous bleeding, and oroantral communication) were also evaluated within this period. RESULTS: No case of ORN or another surgical complication was observed and there were no differences in the postoperative pain scores between the groups on the 3rd and 7th days. CONCLUSIONS: L-PRF did not seem to provide any additional benefits than those achieved by the combination of the surgical and drug protocols used for tooth extractions in the post-irradiated HNC patients

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Seguimiento del cáncer de cabeza y cuello tratado. Lo que el radiólogo debe conocer / Follow-up in head and neck cancer. What the radiologist must know

El manejo de los pacientes con cáncer de cabeza y cuello implica un tratamiento multidisciplinar con cirugía, radioterapia y quimioterapia. Las pruebas de imagen son cruciales en su seguimiento, sobre todo cuando la recurrencia tumoral no sea clínicamente evidente. Distinguir radiológicamente los cambios postratamiento de una recidiva tumoral constituye un reto debido a la alteración anatómica que suponen las técnicas quirúrgicas y sus reconstrucciones, al tratamiento radioterápico y a las pautas quimioterápicas. El diagnóstico diferencial debe incluir las posibles complicaciones derivadas de la radioterapia (necrosis mucosa, osteorradionecrosis, vasculopatía, radionecrosis cerebral) y de la cirugía (infecciones de la herida, necrosis del colgajo, fístulas, etc.). Un amplio conocimiento de los hallazgos esperables del tratamiento multimodal y sus complicaciones es esencial para un diagnóstico preciso de recurrencia tumoral. Por último, elegir la prueba de imagen adecuada y disponer de un estudio basal postratamiento es igualmente relevante para un control radiológico idóneo

The management of patients with head and neck cancer implies a multidisciplinary treatment with surgery, radiotherapy and chemotherapy. Imaging is crucial in their follow-up, especially when the tumor recurrence is not clinically evident. Radiologically distinguishing post-treatment changes from a tumor recurrence is a challenge due to the anatomical alteration due to surgical techniques and their reconstructions, radiotherapy treatment and chemotherapeutic guidelines. The differential diagnosis must include the possible complications derived from radiotherapy (mucosal necrosis, osteoradionecrosis, vasculopathy, cerebral radionecrosis) and surgery (wound infections, flap necrosis, fistulas,...). A wide knowledge of the expected findings of multimodal treatment and its complications is essential for an accurate diagnosis of tumor recurrence. Finally, choosing the appropriate image study and having a baseline post-treatment study is also relevant for a suitable radiological control

Radioterapia en colgajos peroneos. Revisión de la densidad ósea en colgajos peroneos irradiados frente a no irradiados / Radiotherapy in fibular flaps. Review of bone density and complications after radiotherapy

INTRODUCCIÓN: El colgajo peroneo es actualmente una de las técnicas más elegidas para la reconstrucción de defectos mandibulares. Muchos de los pacientes reconstruidos con este colgajo presentan patología oncológica que precisa tratamiento adyuvante con radioterapia. Los efectos adversos de la radioterapia sobre los tejidos son conocidos, pudiendo desembocar en osteorradionecrosis. El objetivo de este estudio es el análisis de la densidad ósea de los colgajos peroneos en los pacientes que han recibido radioterapia frente a los que no, y su posible correlación con las complicaciones posteriores. MATERIAL Y MÉTODOS: Realizamos un estudio retrospectivo de los colgajos peroneos realizados por nuestro servicio desde enero de 2011 hasta diciembre de 2016. Los criterios de inclusión de los pacientes fue el haber sido reconstruidos con un colgajo peroneo y disponer de un TC de control a los tres meses postradioterapia en caso de haberla precisado. Se recogió la edad, densidad ósea peronea, desviación estándar cuerpo mandibular remanente y colgajo peroneo, así como las complicaciones postoperatorias. Los datos extraídos fueron analizados a través del Software SAS (Statistical Analisys System). RESULTADOS: En total se recogieron 61 pacientes, siendo la media de edad de 54,46 años. De estos 61 pacientes se excluyeron 11 al no presentar TC de control, de los 50 pacientes restantes, 27 recibieron tratamiento radioterápico adyuvante (54 %) mientras 23 no la recibieron (46 %). En los pacientes irradiados un alto porcentaje (84,62 %) recibieron altas dosis de radioterapia (> 60 Gy). Se encontraron diferencias estadísticamente significativas (p < 0,05) respecto a la edad y la desviación estándar de la densidad ósea del cuerpo mandibular remanente, mientras que en el resto de los parámetros no se encontraron diferencias estadísticamente significativas. Los pacientes irradiados presentaron un mayor porcentaje de complicaciones frente a los pacientes no irradiados sin diferencias estadísticamente significativas. DISCUSIÓN Las nuevas técnicas de radioterapia de intensidad modulada permiten una dosis relativamente uniforme en un objetivo, evitando altas dosis en los tejidos circuncidantes. A pesar del avance en las técnicas de radioterapia, actualmente en la mayoría de centros se continúa realizando un tratamiento completo del volumen del lecho tumoral, que incluye en el campo de irradiación el colgajo con el que se reconstruye. Los casos de osteonecrosis mandibular que se presentaron fueron en pacientes irradiados y a nivel del cuerpo mandibular remanente. La densidad ósea a nivel del colgajo peroneo sí que presentó diferencias estadísticamente significativas en pacientes irradiados frente a no irradiados; este aspecto puede influir en el índice de complicaciones. CONCLUSIONES: Consideramos con los resultados del estudio, plantear nuevos estudios prospectivos para valorar la necesidad de irradiar el tejido óseo del colgajo peroneo como parte del volumen del lecho tumoral, siendo que este tejido no ha estado en contacto con el tumor primario, ante el mayor índice de complicaciones asociados a la radioterapia en estos tejidos

INTRODUCTION: The fibular flap is currently one of the most chosen techniques for the reconstruction of mandibular defects. Many of the patients reconstructed with this flap present oncological pathology that requires adjuvant treatment with radiotherapy. The adverse effects of radiotherapy on tissues are known, and can lead to Osteorradionecrosis. The aim of this study is to analyze the bone density of peroneal flaps in patients who have received radiotherapy against those who do not and their possible correlation with subsequent complications. MATERIAL AND METHODS: We designed a retrospective study of the fibular flaps performed by our service from January 2011 to December 2016. The criteria for inclusion of patients was to have been reconstructed with a peroneal flap and have a control CT at 3 months after radiotherapy. Age, bone density, standard deviation and further complications were extracted. The extracted data was analyzed through the SAS (statistical Analisys System) Software. RESULTS: 61 patients were collected; the mean age was of 54.46 years. Of these 61 patients were excluded 11 by not presenting control TC, of the 50 patients remaining, 27 received adjuvant radiotherapy treatment (54 %) while 23 did not receive (46 %). In irradiated patients a high percentage (84.62 %) received high doses of radiotherapy (> 60 Gy). Statistically significant differences were found (p < 0.05) with respect to age and standard deviation of bone density of the remaining mandibular body, while in the rest of the parameters no statistical significant differences were found. Irradiated patients presented a higher percentage of complications compared to non-irradiated patients without statistically significant differences. DISCUSSION: The new techniques of intensity-modulated radiotherapy allow a relatively uniform dose in a target, avoiding high doses in the circumcising tissues. Despite the progress in radiotherapy techniques, currently in most centers, it continues to perform a complete treatment of the volume of the tumor bed that includes in the field of irradiation the flap with which it is reconstructed. The cases of mandibular osteonecrosis that were presented were in irradiated patients and in the remaining mandible. Bone density at the level of the fibular flap showed statistically significant differences in irradiated patients compared to non-irradiated, this aspect may influence in the index of complications. CONCLUSIONS: We consider to propose new prospective studies to assess the need to irradiate the bone tissue of the fibular flap as part of the volume of the tumor bed, knowing that this tissue has not been in contact with the primary tumor, and the high index of complications associated with radiotherapy

Fracturas patológicas de mandíbula en pacientes adultos mayores: presentación de una serie de 15 casos / Pathological fractures of the mandible In elderly patiens. a series of 15 cases

INTRODUCCIÓN: Las fracturas patológicas de mandíbula representan menos del 2 % del total de las fracturas de mandíbula y frecuentemente afectan a pacientes adultos mayores. En pacientes mayores de 65 años estas fracturas podrían presentar características diferentes a las de la población general por su asociación con múltiples comorbilidades. MATERIALES Y MÉTODOS: Presentamos un estudio descriptivo retrospectivo de una serie de 15 casos de fracturas patológicas de mandíbula. Solo se incluyeron pacientes mayores de 65 años y se recolectaron las siguientes variables: sexo, edad, etiología, localización, tratamiento y complicaciones postoperatorias. Además se llevó a cabo una revisión de la literatura en PubMed acerca de fracturas patológicas de mandíbula. RESULTADOS: La edad promedio fue de 72 años (rango: 65-85) y el 67 % (n = 10) de los casos fueron pacientes de sexo femenino. La etiología más frecuente fue la osteonecrosis asociada a medicamentos (ONAM) (40 %). La tasa de complicaciones postoperatorias fue del 53 % (8/15). En la revisión de la bibliografía se identificaron 24 artículos acerca de fracturas patológicas de mandíbula. Solo tres publicaciones incluyen más de 10 PACIENTES: Ninguna incluye pacientes adultos mayores exclusivamente. CONCLUSIONES: En nuestra serie encontramos que la etiología más frecuente fue la ONAM. Estos pacientes pueden ser tratados de forma exitosa siguiendo los algoritmos propuestos para la población general, aunque la tasa de complicaciones es elevada (53 %)

INTRODUCTION: Pathological fractures of the mandible account for fewer than 2 % of all mandibular fractures and often affect elderly patients. In patients over 65 years of age, these fractures may present features that are different from those observed in the general population because of their association with multiple comorbidities. MATERIALS AND METHODS: In this paper, we present a retrospective study of a series of 15 cases of pathological fractures of the mandible. Only patients over 65 years old were included, and the following variables were collected: sex, age, etiology, localization, treatment and postoperative complications. Additionally, we conducted a literature review in PubMed on pathological fractures of the mandible. RESULTS: The mean age was 72 years (range 65-85) and 67 % (n=10) were female patients. The most common etiology was medicine-related osteonecrosis of the jaws (40 %). The postoperative complication rate was 53 % (8/15). We identified 24 articles assessing pathological fractures of the mandible in our review of the literature. Only three articles included more than 10 patiens. None of them related exclusively to elderly patients. CONCLUSIONS: In our series, the most frequently encountered etiology was medicine-related osteonecrosis of the jaws. These patients can be treated successfully following the same algorithms used in the general population, albeit the complication rate is high (53 %)

Radioterapia en colgajos peroneos. Revisión de la densidad ósea y complicaciones en colgajos peroneos irradiados frente a no irradiados / Effects of radiotherapy in fibular free flaps. Study of bone density and complications in irradiated fibular flaps vs no irradiated

INTRODUCCIÓN: El colgajo peroneo es actualmente una de las técnicas más elegidas para la reconstrucción de defectos mandibulares. Muchos de los pacientes reconstruidos con este colgajo presentan patología oncológica que precisa tratamiento adyuvante con radioterapia. Los efectos adversos de la radioterapia sobre los tejidos son conocidos, pudiendo desembocar en osteoradionecrosis. El objetivo de este estudio es el análisis de la densidad ósea de los colgajos peroneos en los pacientes que han recibido radioterapia frente a los que no y su posible correlación con las complicaciones posteriores. MATERIAL Y MÉTODOS: Realizamos un estudio retrospectivo de los colgajos peroneos realizados por nuestro servicio desde enero 2011 hasta diciembre 2016. Los criterios de inclusión de los pacientes fue el haber sido reconstruidos con un colgajo peroneo y disponer de un TC de control a los tres meses postradioterapia en caso de haberla precisado. Se recogió la edad, densidad ósea peronea, desviación estándar cuerpo mandibular remanente y colgajo peroneo, así como las complicaciones postoperatorias. Los datos extraídos fueron analizados a través del Software SAS (Statistical Analisys System). RESULTADOS: En total se recogieron 61 pacientes, siendo la media de edad de 54,46 años. De estos 61 pacientes se excluyeron 11 al no presentar TC de control; de los 50 pacientes restantes, 27 recibieron tratamiento radioterápico adyuvante (54 %), mientras que 23 no la recibieron (46 %). En los pacientes irradiados, un alto porcentaje (84,62 %) recibieron altas dosis de radioterapia (> 60 Gy). Se encontraron diferencias estadísticamente significativas (p < 0,05) respecto a la edad y la desviación estándar de la densidad ósea del cuerpo mandibular remanente, mientras que en el resto de los parámetros no se encontraron diferencias estadísticamente significativas. Los pacientes irradiados presentaron un mayor porcentaje de complicaciones frente a los pacientes no irradiados, sin diferencias estadísticamente significativas. Discusión: Las nuevas técnicas de radioterapia de intensidad modulada permiten una dosis relativamente uniforme en un objetivo, evitando altas dosis en los tejidos circuncidantes. A pesar del avance en las técnicas de radioterapia, actualmente en la mayoría de centros se continúa realizando un tratamiento completo del volumen del lecho tumoral, que incluye en el campo de irradiación el colgajo con el que se reconstruye. Los casos de osteonecrosis mandibular que se presentaron fueron en pacientes irradiados y a nivel del cuerpo mandibular remanente. La densidad ósea a nivel del colgajo peroneo sí que presentó diferencias estadísticamente significativas en pacientes irradiados frente a no irradiados; este aspecto puede influir en el índice de complicaciones. CONCLUSIONES: Consideramos, con los resultados del estudio, plantear nuevos estudios prospectivos para valorar la necesidad de irradiar el tejido óseo del colgajo peroneo como parte del volumen del lecho tumoral, siendo que este tejido no ha estado en contacto con el tumor primario, ante el mayor índice de complicaciones asociados a la radioterapia en estos tejidos

INTRODUCTION: The fibular flap is currently one of the most chosen techniques for the reconstruction of mandibular defects. Many of the patients reconstructed with this flap present oncological pathology that requires adjuvant treatment with radiotherapy. The adverse effects of radiotherapy on tissues are known, and can lead to osteoradionecrosis. The aim of this study is to analyze the bone density of peroneal flaps in patients who have received radiotherapy against those who do not and their possible correlation with subsequent complications. MATERIAL AND METHODS: We designed a retrospective study of the fibular flaps performed by our service from January 2011 to December 2016. The criteria for inclusion of patients was to have been reconstructed with a peroneal flap and have a control CT at 3 months after radiotherapy. Age, bone density, standard deviation and further complications were extracted. The extracted data was analyzed through the SAS (statistical Analisys System) Software. RESULTS: 61 patients were collected; the mean age was of 54.46 years. Of these 61 patients were excluded 11 by not presenting control TC, of the 50 patients remaining, 27 received adjuvant radiotherapy treatment (54 %) while 23 did not receive (46 %). In irradiated patients a high percentage (84.62 %) received high doses of radiotherapy (> 60 Gy). Statistically significant differences were found (P < 0.05) with respect to age and standard deviation of bone density of the remaining mandibular body, while in the rest of the parameters no statistical significant differences were found. Irradiated patients presented a higher percentage of complications compared to non-irradiated patients without statistically significant differences. Discussion: The new techniques of intensity-modulated radiotherapy allow a relatively uniform dose in a target, avoiding high doses in the circumcising tissues. Despite the progress in radiotherapy techniques, currently in most centers, it continues to perform a complete treatment of the volume of the tumor bed that includes in the field of irradiation the flap with which it is reconstructed. The cases of mandibular osteonecrosis that were presented were in irradiated patients and in the remaining mandible. Bone density at the level of the fibular flap showed statistically significant differences in irradiated patients compared to non-irradiated, this aspect may influence in the index of complications. CONCLUSIONS: We consider to propose new prospective studies to assess the need to irradiate the bone tissue of the fibular flap as part of the volume of the tumor bed, knowing that this tissue has not been in contact with the primary tumor, and the high index of complications associated with radiotherapy

Osteoradionecrosis prevalence and associated factors: A ten years retrospective study

BACKGROUND: Osteoradionecrosis (ORN) is one of the most serious complications of head and neck radiotherapy and is considered a public health problem worldwide. This study aims to determine the prevalence and associated factors of ORN in patients undergoing radiotherapy for head and neck malignancy. MATERIAL AND METHODS: A cross-sectional retrospective study was conducted, in which all medical records of patients undergoing head and neck radiation in the period between 2006 to 2015 (10 years) were examined. Clinical and demographic data were extracted. Multivariate Poisson regression analysis with robust variance was employed to access the relationship between ORN and independent variables (p < 0.05; 95% CI). RESULTS: The sample comprised 413 medical records of patients undergoing radiotherapy. The prevalence of ORN was 9.7 %. Most participants were males (78.2%). The mean age of subjects was 55 years (± 14 years). The mandible was the main site of occurrence of ORN (85.0%). The following variables were associated with ORN: presence of oral mucositis (PR = 3.03; 95% CI: 1.30-7.03), history of smoking (PR = 0.23; 95% CI: 0.07-0.74), number of teeth removed before radiotherapy (PR = 1.06; 95% CI: 1.01-1.11) and visit to the dentist before radiation (PR = 0.08; 95% CI: 1.02-1.11). CONCLUSIONS: The prevalence of ORN was low and was associated with the presence of oral mucositis and the number of removed teeth before radiation. Visiting the dentist before radiotherapy and stopping smoking were protective factors for ORN

Periodontal therapy for patients before and after adiotherapy: A review of the literature and topics of interest for clinicians

BACKGROUND: This article aims to demonstrate the importance of the TMJ (Temporomandibular Joint) decompression in the treatment of degenerative processes and disc displacements, reporting two clinical cases treated with orthopedic and decompressive correction of TMJ. Material and METHODS: The studies reported in this article show patients with muscle and joint pain who were evaluated pre and post-treatment through MRI (Magnetic Resonance Irradiation) to follow-up bone marrow regeneration and TMJ disc placement. Transcutaneous electrical stimulation (TENS), measurement equipment and IO (Intraoral Orthotic) were used to evaluate and treat the patients. A critical review of literature has also been conducted to confront clinical outcomes. RESULTS: Marrow bone regeneration and disc placement were observed in both patients. CONCLUSIONS: The use of measurement equipment associated with TENS to find the correct rest position of the Jaw an the use of IO to decompress the TMJ was an effective way to promote bone marrow regeneration and disc placement, consequently improving function and quality of life

Tratamiento local de un faringostoma secundario a osteorradionecrosis / Local treatment of a pharyngocutaneous fistula secondary to osteoradionecrosis

La osteorradionecrosis es una complicación tardía y de difícil manejo que se produce como consecuencia de los tratamientos con radioterapia realizados en los tumores de cabeza y cuello. Ocasiona importantes daños, no solo en la piel sino también en estructuras musculares, nerviosas, vasculares y óseas produciendo una afectación de las vías aérea y digestiva que condicionan una pérdida funcional y un defecto estético que suele precisar de cirugía reconstructiva para su reparación. Este proceso lleva asociado una importante pérdida en la calidad de vida del paciente y conlleva largos ingresos hospitalarios por los tratamientos y medidas de soporte necesarios. En este artículo se describe el tratamiento local de un faringostoma secundario al tratamiento con radioterapia de un carcinoma epidermoide de orofaringe derecha. La lesión apareció a los dos meses tras finalizar la radioterapia, y precisó reconstrucción quirúrgica con un colgajo miocutáneo para reparar el defecto tisular. En este contexto, se ha utilizado un apósito de alginato con plata asociado a una espuma de poliuretano de adherencia media con reborde de silicona, consiguiendo en el plazo de un mes el desbridamiento autolítico de todo el tejido necrótico y la aparición de tejido de granulación, a la vez que se controló la infección y se consiguió un mejor manejo del exudado, proporcionando así un lecho quirúrgico adecuado para la reconstrucción

Radionecrosis is a late, and difficult to treat, complication of radiotherapy performed on head and neck tumours, and it is difficult to treat. This process causes significant damage, not only in the skin, but also in muscular, nervous, vascular, and bone structures. This, in turn, leads to airway and digestive tract involvement, as well as a functional loss and a cosmetic defect that usually requires reconstructive surgery. Therefore, this process is associated with a significant loss in the quality of life of patients and involves a long hospital stay for treatment, as well as the necessary support measures. This article describes the local treatment of pharyngocutaneous fistula secondary to radiation therapy of squamous cell carcinoma of the right oropharynx. The lesion appeared two months after completing this treatment and required surgical reconstruction with a myocutaneous flap to repair the tissue defect. In this context, an alginate wound dressing with silver was used, combined with a medium grip polyurethane foam with a silicone border. Within one month, there was autolytic debridement of all the necrotic tissue and the appearance of granulation tissue. At the same time, the infection was controlled, and a better management of the exudate was obtained, which provided a suitable surgical bed for the reconstruction

Reconstrucción de defectos de cavidad oral con colgajos tipo FAMM (colgajo músculo-mucoso de arteria facial). Nuestra experiencia / Reconstruction of oral cavity defects with FAMM (facial artery musculomucosal) flaps. Our experience

Introducción y objetivos: El colgajo músculo-mucoso de arteria facial (FAMM) es un buen recurso para la cobertura de defectos intraorales de pequeño y mediano tamaño debido a sus características tisulares y a su facilidad de realización. Métodos: Revisión retrospectiva de los resultados obtenidos con el colgajo, realizados en nuestro centro durante el periodo 2006-2014. Se intervino a un total de 20 pacientes sobre los que se realizaron 25 colgajos tipo FAMM, 16 derechos (64%) y 9 izquierdos (36%). El colgajo se utilizó de forma bilateral y simultánea en 5 pacientes. Las indicaciones para la realización de los colgajos fueron: reconstrucción tras exéresis de neoplasias del suelo de la boca (8 casos; 40%), neoplasias en otras localizaciones de cavidad oral (4 casos; 20%), osteorradionecrosis mandibular (4 casos; 20%), fístula oroantral (3 casos; 15%) y anquiloglosia posquirúrgica (un caso; 5%). Resultados: El colgajo consiguió una reconstrucción satisfactoria en el 92% de los casos (n = 23). Se produjo una necrosis del colgajo en una ocasión, y una dehiscencia con exposición de hueso subyacente en otra ocasión. Se consiguió una ingesta y función oral satisfactoria en la totalidad de los pacientes. Conclusiones: Dada su fiabilidad y versatilidad, el colgajo músculo-mucoso de arteria facial es una técnica adecuada para la reconstrucción de defectos orales de pequeño y mediano tamaño. Permite una reconstrucción funcional adecuada de la cavidad oral con escaso riesgo de complicaciones (AU)

Introduction and objectives: The facial artery musculomucosal (FAMM) flap is a good option for covering small and medium-sized defects in the oral cavity because of its similar tissue characteristics and easy implementation. Methods: We reviewed our results using this flap between 2006 and 2014. A total of 20 patients were included and 25 FAMM flaps were performed, 16 right (64%) and 9 left (36%) flaps. Five patients had simultaneous bilateral reconstructions. The indications for flap surgery were reconstruction after resection of tumours in the floor of the mouth (8 cases, 40%), tumours in other sites of the oral cavity (4 cases, 20%), mandibular osteoradionecrosis (4 cases, 20%), oroantral fistula (3 cases, 15%) and postoperative ankyloglossia (one case, 5%). Results: Reconstruction was successful in 92% of cases (n = 23). Total flap necrosis occurred in one case and dehiscence with exposure of bone in another. Oral function and ingestion were satisfactory in all patients. Conclusions: The facial artery musculomucosal flap is reliable and versatile for reconstruction of small and medium-sized intraoral defects. It allows functional reconstruction of the oral cavity with a low risk of complications (AU)

Patologías tratadas con oxigenoterapia hiperbárica en el Hospital Central de la Defensa / Pathologies treated with hyperbaric oxygen therapy in The Central Hospital of Defense

INTRODUCCIÓN: La oxigenoterapia hiperbárica (OHB) es una modalidad terapéutica que se fundamenta en la obtención de presiones parciales de oxígeno elevadas en sangre, al respirar oxígeno puro, en el interior de una cámara hiperbárica a una presión superior a la atmosférica. Sus acciones incluyen efectos hemodinámicos, acciones sobre la inmunidad y el transporte de O2. Este amplio espectro de efectos facilita que sus recomendaciones puedan incluir una gran variedad de indicaciones, algunas de ellas controvertidas. OBJETIVOS: Conocer las patologías de los pacientes tratados con OHB en la Comunidad Autónoma de Madrid (CAM) y revisar la evidencia científica al respecto. MÉTODO: En la actualidad la cámara hiperbárica del Servicio de MSB (Medicina Subacuática) del HCD (Hospital Central de la Defensa) es la de referencia en la CAM. Se revisaron las historias clínicas de los pacientes atendidos entre Febrero 2013 y Junio 2014. Se recogieron las siguientes variables: 1) Enfermos aceptados y desestimados para el tratamiento. 2) Edad y sexo de los pacientes tratados. 3) Patología por la que se indicaba el tratamiento. 4) Complicaciones observadas en relación con la OHB. RESULTADOS: Se aceptaron para tratamiento 113 enfermos procedentes de 15 Hospitales de la CAM. Se desestimaron para tratamiento con OHB a 22 pacientes por patologías o tratamientos activos que no hacían aconsejable el tratamiento con OHB en ese momento. El 59,82 % eran hombres y el 40,18 % mujeres. Edad media 64,72 años. Las indicaciones principales de tratamiento fueron las lesiones radio inducidas 52,21 % de los casos (n=59) y las úlceras y heridas de evolución tórpida con mala respuesta a tratamiento convencional 23 % de los casos (n=26). El tratamiento tuvo que ser suspendido en 8 pacientes (7,14 % de los tratados) por mala tolerancia o complicaciones leves. DISCUSIÓN Y CONCLUSIONES: Las indicaciones de OHB en nuestra muestra comprenden un amplio número de patologías. Las lesiones radio inducidas son la indicación más frecuente de los enfermos tratados con OHB en el HCD. En este grupo destaca la osteorradionecrosis de mandíbula (ORNM) tras radioterapia (RT) en tumores de cabeza y cuello. Todas las indicaciones de OHB de la muestra presentada cuentan con estudios que avalan su uso, aunque no existen para ninguna de ellas estudios randomizados controlados, doble ciego. Las complicaciones que observamos en el tratamiento con OHB en nuestra muestra son leves por lo que la podemos considerar un tratamiento seguro. Creemos que la OHB ofrece una gran oportunidad para investigar la evidencia científica firme que avale sus indicaciones en discusión

INTRODUCTION: Hyperbaric oxygen therapy (HBOT) is a therapeutic modality that is based on obtaining high partial pressures of oxygen in blood, breathing pure oxygen inside a hyperbaric chamber at a pressure above atmospheric. Their actions include hemodynamic effects, actions on immunity and O2 transport. This broad spectrum of effects makes its recommendations may include a variety of indications, some of them controversial. OBJECTIVES: To know the pathologies of patients treated with HBO in the Autonomous Community of Madrid (CAM) and review the scientific evidence for this. METHOD: At present the hyperbaric chamber MSB Service (Underwater Medicine) HCD (Central Hospital of Defense) is the reference in the CAM. The medical records of patients treated between February and June-13-14 were reviewed. The following variables were collected: 1) Sick accepted and rejected for treatment. 2) Age and sex of patients treated. 3) Patho-logy for which treatment is indicated. 4) Complications observed in connection with HBO. RESULTS: 113 patients accepted for treatment from 15 hospitals in the CAM. Were rejected for HBO therapy for pathologies 22 patients or active treatments did not advisable HBO therapy at that time. The 59.82% were male and 40.18% female. Mean age 64.72 years. The main indica-tions for treatment were within lesions induced 52.21% of cases (n = 59) and ulcers and wounds torpid with poor response to conventional treatment 23% of cases (n = 26). The treatment had to be suspended in 8 patients (7.14% treated) by poor tole-rance or mild complications. DISCUSSION AND CONCLUSIONS: The indications for HBO in our sample comprises a large number of pathologies. Radio induced injuries are the most common indication for patients treated with HBO in the HCD. In this group highlights the jaw osteoradionecrosis (ORNM) after radiotherapy (RT) in head and neck tumors. All indications OHB sample have presented studies supporting its use, although there are none for randomized controlled trials, double-blind. The complications observed in the HBO treatment in our sample are mild so we can consider it a safe treatment. We believe that HBO offers a great opportunity to investigate the firm scientific evidence to support its indications discussion

Proposal for a new staging system for osteoradionecrosis of the mandible

A new staging system for osteoradionecrosis of the mandible has been retrospectively applied to a group of 31 patients. In this system clinic radiographic signs and symptoms are incorporated in a simplified manner. For imaging purposes the use of plain radiographs such as periapical films and panoramic radiographs is recommended, mainly because of their readily availability. The presented staging system seems well reproducible, facilitating the comparison of study groups dealing with the various issues of osteoradionecrosis of the mandible. It is yet to be evaluated whether the presently proposed staging system is useful for management purposes

Osteonecrosis maxilar asociada a infección por Actinomyces y tratamiento con bifosfonatos / Actinomyces and bisphosphonate-related osteonecrosis of the jaw

Objetivo. Describir anatomopatológicamente la osteonecrosis maxilar asociada a tratamiento con bifosfonatos y su asociación con infección por Actinomyces spp. Material y método. Se seleccionaron casos con diagnóstico clinicopatológico de necrosis maxilar o mandibular en las bases de datos de los hospitales de La Paz y de Guadalajara. Resultados. Se hallaron 16 casos con constatación anatomopatológica de necrosis ósea maxilomandibular e infección por Actinomyces. En 13 casos se informó de tratamiento con bifosfonatos. Un caso correspondió a osteorradionecrosis infectada. En 2 casos no se informó de tratamiento alguno. Conclusiones. Este cuadro es poco frecuente y suele sospecharse clínicamente, pero es relativamente desconocido para patólogos generales. Constantemente se asocia a infección por Actinomyces spp, que probablemente influya en la patogenia del proceso(AU)

Objetive. To describe pathological features in bisphosphonate-related osteonecrosis of the jaw and Actinomyces spp. infection. Materials and method. All cases, from both our hospitals, with a clinicopathological diagnosis of osteonecrosis of the jaw were reviewed. Results. Sixty cases of osteonecrosis of the jaw and Actinomyces infection are reported. Thirty cases were treated with bisphosphonate, 2 cases were untreated, and one case corresponded to infected osteoradionecrosis. Conclusion. This is a rare disease that is detected usually by clinicians but pathologists should be aware of it. It is constantly associated with, and probably caused by, Actinomyces spp. infection(AU)

Factores de riesgo y prevención del cáncer oral. Actitud del odontólogo / Risk factors and prevention of oral cancer. The attitude of the dental professional

El cáncer oral constituye un grave problema sanitario en muchos países. No sólo genera una mortalidad significativa, sino que también provoca desfiguración extensa, deterioro funcional, cambios conductuales, y problemas económicos y sociológicos. La OMS predice un continuo aumento de esta enfermedad en todo el mundo. En España, la incidencia del cáncer oral es de 12 a 15 casos/100.000 habitantes/año en varones y de 2 a 4 casos/100.000 habitantes/año en mujeres; estos resultados posicionan a nuestro país en una posición intermedia en lo que se refiere a la incidencia de cáncer oral en la Comunidad Europea. La profesión odontológica tiene un papel importante en la lucha contra el cáncer oral cumpliendo una invalorable tarea en todos los niveles de prevención. El objetivo del presente trabajo es presentar una actualización acerca de la actuación del odontólogo en la prevención primaria, secundaria y terciaria del cáncer oral (AU)

Oral cancer is a serious health problem in many countries. It not only generates significant mortality, but also causes extensive disfigurement, loss of function, behavioral changes and economic and sociological problems. The World Health Organization (WHO) predicts a continuous increase of this disease worldwide. In Spain, the incidence of oral cancer is 12 to 15 cases per 100,000 / year in males and 2-4 cases per 100,000 / year in women, these results positioning Spain in an intermediate position in relation to the incidence of oral cancer in the European Community. The dental profession has an important role in the fight against oral cancer, fulfilling an invaluable task in all levels of prevention. The aim of this paper is to present an update on the performance of the dentist in the primary, secondary and tertiary prevention of oral cancer (AU)

Osteorradionecrosis como secuela de la radioterapia / Osteoradionecrosis like radiotherapy's sequel

La osteorradionecrosis es una de las más graves complicaciones derivadas de cabeza y cuello por la terapia de radiación, se describe como una alteración ósea en la que hay desvitalización del hueso, con hipovascularización, hipocelularidad (fibroblastos, osteoclastos, células indiferenciadas osteogénicas), e hipoxia tisular local. Ocurre espontáneamente o en respuesta a una herida, cuando se somete al paciente a dosis de irradiación por encima de 60 G y, sobre todo, con quimioterapia concomitante. El hueso no puede responder adecuadamente después de traumas locales como extracciones dentales, biopsias para descartar recidivas, enfermedades periodontales, como una serie de condiciones que predisponen a su aparición. Dentro de los factores predisponentes se incluye la dosis de radiación absorbida, el fraccionamiento del tratamiento, modalidad de aplicación y el estado mental. Luego puede aparecer la sintomatología aunque a veces los síntomas aparecen sin desencadenante previo. Esta sintomatología puede reducirse mediante la pronta evaluación, tratamiento y ambientación intraoral, antes de comenzar la regeneración tisular. Para el tratamiento se toman en cuenta los antibióticos, la oxigenoterapia hiperbárica y técnicas quirúrgicas, incluidas hemimandibulectomía y colocación del injerto dependiendo de cada caso (AU)

The osteoradionecrosis is one of the most serious complications of head and neck radiation therapy, is described as a disturbance in which bone is bone desvitalización with hypovascularity, hypocellularity (fibroblasts, osteoclasts, osteogenic cells undifferentiated), and hypoxia local tissue. Occurs spontaneously or in response of a wound when the patient is subjected to irradiation doses above 60 G and especially with concomitant chemotherapy. The bone cannot respond properly after local trauma such as dental extractions, biopsies to rule out recurrence, periodontal diseases. Predisposing factors include the radiation absorbed dose, fractionation, delivery modality, or mental state. After symptoms appear but sometimes trigger symptoms appear without prior approval. This can be reduced through early assessment, treatment and cure intraoral, before the start of tissue regeneration. For the treatment are taken into account antibiotics, hyperbaric oxygen therapy and surgical techniques, including hemimandibulectomy and placement of the graft in each case (AU)

Clinico-therapeutic management of osteoradionecrosis: A literature review and update

In the management of head and neck cancer, radiotherapy is usually a coadjuvant to surgery, or is applied on apalliative basis. The most important complication of such radiotherapy is osteoradionecrosis, which manifests asan area of exposed necrotic bone in the maxillae or mandible that fails to heal during at least three months. In mostcases osteoradionecrosis gradually progresses, becoming more extensive and painful, and its late manifestations comprise infection and pathological fracture.The present study provides a literature review and update on the risk factors underlying osteoradionecrosis, its clinical and diagnostic particulars, prevention, and most widely accepted treatment options, as well as new possibilities relating to clinical management of the disorder. Lastly, a new early management protocol is proposed based on the current consensus criteria relating to maxillary osteonecrosis secondary to treatment with bisphosphonates,together with the adoption of new therapies supported by increased levels of evidence (AU)

Doble injerto microvascularizado de peroné para reconstrucción bilateral mandibular por osteorradionecrosis / Double-barrel microvascularised fibular graft for bilateral mandibular reconstruction due to osteoradionecrosis

La osteorradionecrosis mandibular supone una complicación grave del tratamiento radioterápico, que a menudo origina una seria deformidad facial. La dificultad para la masticación, la articulación y la deglución son también frecuentes. A pesar de los avances realizados en la última década en radioterapia para tumores de la cabeza y el cuello, las complicaciones por osteorradionecrosis aún se producen. La indicación para una cirugía radical no está claramente definida, pero esta modalidad de tratamiento debe instaurarse cuando las medidas conservadoras han fracasado o cuando prevalece la necrosis ósea y de partes blandas. Las fracturas patológicas o fístulas persistentes son claros indicadores para un abordaje radical. En este artículo se presenta un caso de osteorradionecrosis bilateral mandibular tratada con amplia extirpación quirúrgica y reconstrucción en dos tiempos con dos injertos microvascularizados de peroné(AU)

Osteoradionecrosis of the mandible is a serious complication of radiotherapy that often leads to severe facial deformity. Difficulties in mastication, articulation, and swallowing are also common. Despite major improvements in radiation therapy of head and neck cancers during the last decade, osteoradionecrosis complications still occur. The indication for radical surgery is not clearly defined, but this kind of treatment should only be instituted when conservative methods fail or when severe bone and soft-tissue necrosis prevails. Pathological fractures or persistent fistulas are strong indications for a more radical surgical approach. This article reports a case of bilateral osteoradionecrosis of the mandible treated with radical escision and reconstruction in two stages with two fibular osteoseptocutaneous free flaps(AU)

Osteonecrosis of the jaws by intravenous bisphosphonates andosteoradionecrosis: A comparative study

Aims: We analyze the possible clinical differences between bone jaw exposed areas in ONJ (osteonecrosis of thejaws) and ORN (osteoradionecrosis).Patients and method: Group 1 was composed with 53 ONJ cases and group 2 with 20 ORN cases. In both groupswe analyzed, the major size of the exposed bone areas, the number of exposed areas, the location on the jaws andthe presence of others associated and severe complications, such as skin fistulas and jaw fractures. We also investigatedthe possible local aetiology or trigger factor of the lesions.Results: The major size of the bone exposed areas was 2.29±2.02(mean ± std.dev) in group 1 and 2.7±2.9 (mean ±std.dev) in group 2 (p>0.05). The number of exposed areas was 1.8±1.34 (mean ± std.dev) in group 1 and 1.2±0.55(mean ± std.dev) in group 2 (p>0.05). There were more fractures in the second group (20%) (p<0.05), and skinfistulas (35%) (p<0.05). We found more patients in group 1 in which the dental extraction was the local aetiologyof the bone necrosis (35 cases, 66.03%), while in group 2 there were 8 (40%) (p<0.05).Conclusions: In our study with ONJ there were not differences in the major size of the bone exposed areas, butthere were more lesions per patient than in group with ORN. The severity of the complications, such as jaw fracturesand skin fistulas were higher in ORN, and in this group it was more frequent the spontaneous lesions than inthe ONJ where it is more frequent following dental extractions (AU)

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